Tell us how we can help

Email *

Phone Number

Phone Extension (if required)

In order to best help you, can you tell me if you are... *

<div class="nested_field">
<div class="form-group ">
  <label for="helpdesk_ticket_custom_field_cf_pt_my_situation_is_4441359" class="form-label">
  	My situation is...
		
    
  </label>

<select
  	class="form-control parent_field nested_select_field choices "
  	id="helpdesk_ticket_custom_field_cf_pt_my_situation_is_4441359"
  	name="helpdesk_ticket[custom_field][cf_pt_my_situation_is_4441359]"
  	
  	
    
    	data-nested-choices = "[[&quot;I am a current patient and need help with my device&quot;,&quot;I am a current patient and need help with my device&quot;,[[&quot;I need a refill code&quot;,&quot;I need a refill code&quot;,[]],[&quot;I am seeing a code starting with \&quot;C\&quot; on the screen&quot;,&quot;I am seeing a code starting with \&quot;C\&quot; on the screen&quot;,[]],[&quot;I need to get accessories (e.g., goggles)&quot;,&quot;I need to get accessories (e.g., goggles)&quot;,[]],[&quot;I don&#39;t have a treatment plan from my physician, can you provide guidance?&quot;,&quot;I don&#39;t have a treatment plan from my physician, can you provide guidance?&quot;,[]],[&quot;My device is locked and I don&#39;t remember the unlock code&quot;,&quot;My device is locked and I don&#39;t remember the unlock code&quot;,[]],[&quot;My device doesn&#39;t turn on&quot;,&quot;My device doesn&#39;t turn on&quot;,[]],[&quot;I think my lamp needs to be replaced&quot;,&quot;I think my lamp needs to be replaced&quot;,[]],[&quot;I no longer need the device. What can I do with it?&quot;,&quot;I no longer need the device. What can I do with it?&quot;,[]],[&quot;Another topic&quot;,&quot;Another topic&quot;,[]]]],[&quot;I am a new patient, and my device has just arrived. I need help getting started&quot;,&quot;I am a new patient, and my device has just arrived. I need help getting started&quot;,[[&quot;I need help setting up the device (e.g., assembly)&quot;,&quot;I need help setting up the device (e.g., assembly)&quot;,[]],[&quot;I need help turning the device on for the first time&quot;,&quot;I need help turning the device on for the first time&quot;,[]],[&quot;I need help with my 1st treatment&quot;,&quot;I need help with my 1st treatment&quot;,[]],[&quot;My device has a missing part&quot;,&quot;My device has a missing part&quot;,[]],[&quot;Another topic&quot;,&quot;Another topic&quot;,[]]]],[&quot;My doctor just prescribed Phothera&#39;s device, and I would like to know the next steps&quot;,&quot;My doctor just prescribed Phothera&#39;s device, and I would like to know the next steps&quot;,[[&quot;My doctor sent a prescription and said someone from Phothera will contact me. When can I expect to hear from your team?&quot;,&quot;My doctor sent a prescription and said someone from Phothera will contact me. When can I expect to hear from your team?&quot;,[]],[&quot;I spoke with your team, and I am checking on the status of my Prior Authorization&quot;,&quot;I spoke with your team, and I am checking on the status of my Prior Authorization&quot;,[]],[&quot;I have signed the paperwork and would like to know when you plan to ship my device&quot;,&quot;I have signed the paperwork and would like to know when you plan to ship my device&quot;,[]],[&quot;I received a notification that my device shipped, but it hasn&#39;t arrived yet&quot;,&quot;I received a notification that my device shipped, but it hasn&#39;t arrived yet&quot;,[]],[&quot;Another topic&quot;,&quot;Another topic&quot;,[]]]],[&quot;I don&#39;t have a device yet, so I&#39;m looking for more information about phototherapy to find the best one for me&quot;,&quot;I don&#39;t have a device yet, so I&#39;m looking for more information about phototherapy to find the best one for me&quot;,[[&quot;I want to understand the differences between the devices&quot;,&quot;I want to understand the differences between the devices&quot;,[]],[&quot;I would like to know the cost of your devices&quot;,&quot;I would like to know the cost of your devices&quot;,[]],[&quot;I want to know if insurance covers phototherapy? Do you work with different insurers?&quot;,&quot;I want to know if insurance covers phototherapy? Do you work with different insurers?&quot;,[]],[&quot;I want materials I can show to my doctor&quot;,&quot;I want materials I can show to my doctor&quot;,[]],[&quot;Another topic&quot;,&quot;Another topic&quot;,[]]]],[&quot;Other Situation&quot;,&quot;Other Situation&quot;,[]]]"
  	
    	data-selected-choices = "null"
  	
    	data-nested-levels = "[{&quot;id&quot;:158000001322,&quot;label&quot;:&quot;Pt - I am reaching out because...&quot;,&quot;label_in_portal&quot;:&quot;I am reaching out because...&quot;,&quot;name&quot;:&quot;cf_pt_i_am_reaching_out_because_4441359&quot;,&quot;level&quot;:2,&quot;field_type&quot;:&quot;nested_child&quot;}]"
  	
    	data-placeholder = ""
  	
    	data-required-field = "false"
  	
  >
   
     <option value>Choose...</option>

<option  data-custom-properties='{"id": ""}' value="I am a current patient and need help with my device">
          I am a current patient and need help with my device
         </option>
       
         <option  data-custom-properties='{"id": ""}' value="I am a new patient, and my device has just arrived. I need help getting started">
          I am a new patient, and my device has just arrived. I need help getting started
         </option>
       
         <option  data-custom-properties='{"id": ""}' value="My doctor just prescribed Phothera&#39;s device, and I would like to know the next steps">
          My doctor just prescribed Phothera's device, and I would like to know the next steps
         </option>
       
         <option  data-custom-properties='{"id": ""}' value="I don&#39;t have a device yet, so I&#39;m looking for more information about phototherapy to find the best one for me">
          I don't have a device yet, so I'm looking for more information about phototherapy to find the best one for me
         </option>
       
         <option  data-custom-properties='{"id": ""}' value="Other Situation">
          Other Situation
         </option>

</select>

<div class="nested_field">
<div class="form-group ">
  <label for="helpdesk_ticket_custom_field_cf_hcp_my_situation_is_4441359" class="form-label">
  	My situation is...
		
    
  </label>

<select
  	class="form-control parent_field nested_select_field choices "
  	id="helpdesk_ticket_custom_field_cf_hcp_my_situation_is_4441359"
  	name="helpdesk_ticket[custom_field][cf_hcp_my_situation_is_4441359]"
  	
  	
    
    	data-nested-choices = "[[&quot;I am inquiring on behalf of a patient with a home device….&quot;,&quot;I am inquiring on behalf of a patient with a home device….&quot;,[[&quot;I need a refill code for my patient...&quot;,&quot;I need a refill code for my patient...&quot;,[]],[&quot;I am checking on the status of the prescription I sent for my patient.&quot;,&quot;I am checking on the status of the prescription I sent for my patient.&quot;,[]]]],[&quot;I need help with our clinic&#39;s phototherapy device…&quot;,&quot;I need help with our clinic&#39;s phototherapy device…&quot;,[[&quot;I need to schedule a PM for our devices...&quot;,&quot;I need to schedule a PM for our devices...&quot;,[]],[&quot;Our device needs troubleshooting...&quot;,&quot;Our device needs troubleshooting...&quot;,[]],[&quot;We no longer need the devices. What can we do with them?&quot;,&quot;We no longer need the devices. What can we do with them?&quot;,[]]]],[&quot;I want to initiate phototherapy for my patients…&quot;,&quot;I want to initiate phototherapy for my patients…&quot;,[[&quot;I want to start prescribing home phototherapy devices.&quot;,&quot;I want to start prescribing home phototherapy devices.&quot;,[]],[&quot;I want to incorporate phototherapy into my clinic.&quot;,&quot;I want to incorporate phototherapy into my clinic.&quot;,[]],[&quot;I want to start both - prescribing home devices and clinic-based therapy.&quot;,&quot;I want to start both - prescribing home devices and clinic-based therapy.&quot;,[]],[&quot;I want to set my practice on Clearlink (Phothera&#39;s physician portal)&quot;,&quot;I want to set my practice on Clearlink (Phothera&#39;s physician portal)&quot;,[]],[&quot;How do I prescribe phototherapy with Phothera?&quot;,&quot;How do I prescribe phototherapy with Phothera?&quot;,[]]]]]"
  	
    	data-selected-choices = "null"
  	
    	data-nested-levels = "[{&quot;id&quot;:158000001323,&quot;label&quot;:&quot;HCP - I am reaching out because...&quot;,&quot;label_in_portal&quot;:&quot;I am reaching out because...&quot;,&quot;name&quot;:&quot;cf_hcp_i_am_reaching_out_because_4441359&quot;,&quot;level&quot;:2,&quot;field_type&quot;:&quot;nested_child&quot;}]"
  	
    	data-placeholder = ""
  	
    	data-required-field = "false"
  	
  >
   
     <option value>Choose...</option>

<option  data-custom-properties='{"id": ""}' value="I am inquiring on behalf of a patient with a home device….">
          I am inquiring on behalf of a patient with a home device….
         </option>
       
         <option  data-custom-properties='{"id": ""}' value="I need help with our clinic&#39;s phototherapy device…">
          I need help with our clinic's phototherapy device…
         </option>
       
         <option  data-custom-properties='{"id": ""}' value="I want to initiate phototherapy for my patients…">
          I want to initiate phototherapy for my patients…
         </option>

</select>

<div class="form-group ">
	
		<label for="helpdesk_ticket_custom_field_cf_title_4441359" class=" form-label">
			Your Title
			
			
		</label>

<div class="form-group ">
	
		<label for="helpdesk_ticket_custom_field_cf_company_name_4441359" class=" form-label">
			Organization Name (Clinic or Company)
			
			
		</label>

<div class="form-group ">
	
		<label for="helpdesk_ticket_custom_field_cf_title_4441359" class=" form-label">
			Your Title
			
			
		</label>

<div class="form-group ">
	
		<label for="helpdesk_ticket_custom_field_cf_company_name_4441359" class=" form-label">
			Organization Name (Clinic or Company)
			
			
		</label>

<div class="form-group  helpdesk_ticket_custom_field_cf_d_im_interested_in_learning_more_about_4441359">
    <label for="helpdesk_ticket_custom_field_cf_d_im_interested_in_learning_more_about_4441359" class=" form-label">
    	D - I&#39;m interested in learning more about:
	  	
      
    </label>

<option value>Choose...</option>

<option  data-custom-properties='{"id": "{"data-id"=>158000712385}"}'value="I would like to become a Phothera distributor">
            I would like to become a Phothera distributor
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>158000712386}"}'value="I want general phototherapy information">
            I want general phototherapy information
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>158000712387}"}'value="I need technical support">
            I need technical support
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>158000712388}"}'value="Another topic">
            Another topic
          </option>

</select>

Description of your inquiry

Device Serial Number

Cancel

Please include as much detail as possible. Patient phone must be exactly 10 digits.